Healthcare Provider Details

I. General information

NPI: 1285735142
Provider Name (Legal Business Name): PETER PAUL MAYOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 W WILSON AVE
CHICAGO IL
60640-8090
US

IV. Provider business mailing address

845 W WILSON AVE
CHICAGO IL
60640-8090
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-4283
  • Fax: 773-989-5986
Mailing address:
  • Phone: 773-506-4283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036084492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: